•01-200605-00214 DISEMBER AK USOP •01-200605-00138 NOOR AZURA BT BAKAWI •01-200605-00175 ROZIAH BT ROSLI •01-200605-00170 DIABETES MELLITUS DEFINITION. A syndrome characterized by disordered metabolism and inappropriately high blood sugar (hyperglycaemia) resulting from either low levels of the hormone insulin or from abnormal resistance to insulin’s effects coupled with inadequate level of insulin secretion to compensate. CLASSIFICATION OF DIABETES MELLITUS. ♦ TYPE 1 ♦ Characterized by loss of the insulin- producing beta cells of the islets of langerhans in the pancreas ,leading to a deficiency of insulin. ♦ The main cause of this beta loss is a T- cell mediated autoimmune attack. CON’T… ♦ TYPE 2 ♦ Due to insulin resistance or reduced insulin sensitivity,combined with reduced insulin secretion. ♦ The defective responsiveness of body tissues to insulin almost certainly involves the insulin receptor in cell membranes. ♦ In the early,stage the predominant abnormality is reduced insulin sensitivity,characterized by elevated levels of of insulin in the blood. PATHOPHYSIOLOGY ♦ Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. ♦ The glucose in digested food is absorbed by the intestinal cells into the bloodstream and is carried by blood to all the cells in the body. ♦ However glucose cannot enter the cells alone.It needs assistance from insulin in order to penetrate the cell walls. CON’T… ♦ Insulin therefore acts as a regulator of glucose metabolism in the body. ♦ Insulin is called the “hunger hormone”.As the blood sugar level increases following a carbohydrate rich meal,the corresponding insulin level rises with the eventual lowering of the blood sugar and glucose is transported from the blood into the cell for energy. ♦ When the blood glucose levels are lowered,the insulin release from the pancreas is turned off. CON’T… ♦ When the blood sugar level drops below a certain level,hunger is felt.This often occurs a few hours after the meal. ♦ In normal individuals,such a regulatory system helps to keep blood glucose levels in a tightly controlled range. ♦ Cravings for sweets frequently form part of ths cycle,which can lead to snacking ,often for more carbohydrates. CON’T… ♦ If the cravings are not fulfilled,sensations such as hunger,dizziness,moodiness and a state of “collapse” can result. ♦ This system of auto regulation and homeastasis is the funtion of the pancreas and it works around the clock. ♦ Dysfunction of this auto regulation system-either inability of the pancreas to secrete any or insufficient insulin or pancreas overload from much sugar ingested over a long period of time or over compensatory mechanism or a combinationof these results in the lack of insulin and hence high blood sugar. ETIOLOGY ♦ Obesity(overweight) ♦ Waist size ♦ Sedentary lifestyle ♦ Age ♦ Family history ♦ Ethnicity ♦ Pre-diabetes ♦ Gestational diabetes/high birth weight baby ♦ High blood pressure/cholesterol CLINICAL MANIFESTATION ♦ Polyuria(excessive urination) ♦ Polydipsia(exssive thirst) ♦ Excessive hunger ♦ Fatigue ♦ Blurry vision ♦ Polyphagia ♦ Smell of acetone the patients breath ♦ A rapid,deep breathing(kuss maul breathing) ♦ Lethargy ♦ Recurrent infection CON’T… ♦ Vulvovaginitis ♦ Pruritis ♦ Nocturia ♦ Nonspecific instability of balance ♦ Nausea ♦ Vomiting ♦ Abdominal pain ♦ Weakness ♦ dizziness ♦ Confusion INVESTIGATIONS Fasting blood sugar Casual blood glucose Postload blood glucose Glycosylated hemoglobin Glycosylated albumin OGGT(Oral glucose tolerance test) Ketonuria proteinuria TREATMENT (1)Gliclazide Trade name:diamicron Route:40-80mg daily Indications:diabetes mellitus Side effects:nausea,headache,rashes,GI disturbance. (2)Chlorpropamide Trade name:diabenese Route:250-500mg daily Indications:diabetes mellitus, Side effects:jaundice,disulfiram-like reactions CON’T… (3)Glibenclamide Trade name:daonil,euglucon Route:2.5-15mg dly.(with or immediately after breakfast) Indications:diabetes mellitus,diabetic coma,renal impairment,pregnancy. Side effects:GI disturbance,blood dyscrasia. (4)Glimepiride Trade name:amaryl Route:1mg dly adjusted according to response) Indications:diabetes mellitus Side effects:regular hepatic CON’T… (5)Glipizide Trade name:glibenese,minodiab Route:2.5-5mg dly adjusted according to response Indications:diabetes mellitus Side effects:dizziness,drowsiness. (6)Tolbutamide Trade name:tolbutamide Route:0.5-1.5mg after breakfast Indications:diabetes mellitus Side effects:headache,tinnitus CON”T… (7)Melformin hydrochloride Trade name:glucophage Route:500mg tds,or 850mg 12 hrly with food. Indications:diabetic coma, Side effects:anorexia,nausea,vomiting,diarrhoea (8)Acarbose Trade name:glucobay Indications:controlled by diet or by diet hypogalcemia agents Side effects:soft stool,abdominal didtention and pain CON’T… (9)Insulin recombinant neutral human Trade name:actrapid Route:dose to be individualised Side effects:rare incidence or allergy (10)Insulin recombinant synthetic human Trade name:insulatard Route:dose to be individualised Side effects:rare incidence,or allergy NURSING MANAGEMENT Self management and to become the focus of the team approach to treatment. Assessment of the clients level of a acceptance of personal responsibility is necessary. Administer medications(oral antidiabetes,insulin theraphy). Balancing diet,exercise Promote proper nutrion to improve metabolic control. Change in eating habis or patterns. COMPLICATION Eye complications(diabetic retinopathy) Kidney damage(kidney disease) Nerve damage Heart disease Stroke(brain attack) Urinary incontinence(unable to hold urine) Intestinal distruptions leading to constipation. PATIENT PROFILE Patient x 78 year Rh,kian tg,bijat sri aman 653/08 300105-13-5054 Female Iban(kristian) Married House wife Malaysian NURSING PROGRESS NOTE PM DUTY(17/2/08) Whell chair case,warded at 5.55pm via A&E. On admission,patient concious and alert. V/S:BP:120/80-160/80 PR:86/min TEMP:36.5’C-37’C Tablet Gliclazide 160mg Tablet Haemotinics Tablet Prosojin 1mg Tablet DITP 50mg (served at 6.30pm) Taken food from home CON’T… NPO/BNO since on admission. G/C;Fair Treatment Tab.Adalat 10mg HPC(hypocount) Tab.Lovastatin 20mg (due at 10pm) IVF 3%saline in progress due at 6pm(18/2/08) NURSING PROGRESS NOTE ND(17/2/08) Hpc:11.4mmol Tab.Adalat 10mg Tab.Lovastatin 20 mg (due at 10pm) Tab.Ferrous Fumarate 200mg Tab.Folic Acid 1/1 Mist Nacl 2g Tab Metaprolol 50mg Tab Prazogin 1mg (served at 5am) CON’T… Hpc:5.3mmol BUSE and UFEME taken. Patient afebril BP:140/80-120/80 mmHg PR:84min Urine output:280cc Oral intake:150cc Treatment:IV drip 3% n/s in progress on due 3pm(18/2/08) NURSING PROGRESS NOTE AM(18/2/08) Mist.carbinative 15mls served at 8.45pm. Temperature:normal BP:120/60-130/60 Still complain of weakness&sight giddiness Adu RIB 11.20am HPC:18.8 mmol(after lunch) Taken 1 plate of rice for lunch I/O:300/300 BNO CON’T… Tab.Ferrous Fummerate 200mg Mist Nacl 2gm Tab Adalat 10mg (served at 11.00am) G/C;Fair Treatment -IVF 3% saline in progress due at 4pm -Repeat BUSE at 4pm NURSING PROGRESS NOTE PM(18/2/08) Temp:afebrile BP:145/70-150/80 mmHg PR:75-70min Repeat BUSE taken@4pm-result seen by Dr a(to continue 1 more pint 3% saline over 24 hour.to repeat BUSE at 5pm after complete 3% saline) Mist Nacl 2gm Mist Carbinative 15mls Tab.Gliclazide 160mg Tab.Metropolol 50mg Tab.Prazogin 1mg CON’T… Dinner taken Pass urine I/O recorded G/C:Fair NURSING PROGRESS NOTE ND(18/2/08) Mist Nacl 2g Tab.Lovastatin 20mg Tab.Adalat 10mg Tab Prazogin 1mg Tab Metropolol 50mg Tab Gliclazide 160mg Mist carminative Tab Ferrous Fummerate 1/1 Tab Folic Acid CON’T… Patient afebrile BP:120/70-130/70mmHg I/O;650CC-1200CC HPC:10.6mmol Sleep well Taken breakfast NURSING PROGRESS NOTE AM(19/2/08) Patient”s vital sign stable Nil new complaint Fit for discharge today Adu on (A) given Home at 11.30 am NURSING CARE PLAN (1) Anxiety related to hospitalization. Goal -Patient will verbalise less anxiety Intervention: -assess patients level of a anxiety -explain to patients the important of completing the treatment. -explain to patients regarding procedures. -give emotional support. -involve patients when planning nursing care. Cont’s… ♦ Evaluation: -patient describes at least two situations that increase tension. -patient states at least two ways to eliminate or minimize anxious behaviors. -patient reports being able to cope with current situation without experiencing severe anxiety. Cont’s… (2)Ineffecive health maintenance related to management of type 1 diabetes mellitus. Goal: -patients will describes feeling about self management of types1 diabetes mellitus. -patients will describes disease process. Interventions: -evaluate the patients understanding of types1 diabetes mellitus and attitude about the need to manage it. Cont’s… -correct any misconceptions about type 1 diabetes mellitus and the therapeutic regimen. -discuss peer presure.ask the adolesent if patients feel social pressure that causes to ignore dieter avoid self administering insulin. -ask if patients feel eparrassed about disorder. Evaluations: -patients express feelings about self management of diabetes mellitus. -patients accurately describes disease process of type 1 diabetes mellitus. Cont’s… (3)Nutrition less than body requirements relaed to poor of appetite. Goal: -patients will show no futher evidence of weigth loss. -patients will take in calories daily. Interventions: -obtain and record patients weight at the same time every day to obtain accurate readings. Cont’s… (4)Risk for fluid volume deficit related to hyperglycaemia and osmotic diuresis. Goal: -The diabetic client will exhibit optima fluid balance as evidence by: #Blood pressure > 90/60mmHg (or within the client normal range). #Firm skin torgor and moist mucous membranes. Cont’s… -maintain parental fluids or ordered to provide patiens with needed fluids and electrolytes. -monitor electrolytes level and report abnormal values. Evaluations: -patients remains at or above specified weight. -patients consumes specified number of calories daily. Cont’s… Intervention: -Monitor vital signs every 15min until the client condition is stable for 1hour,then 4 hourly. -Notify the physician if heart rate is > 120/min,blood pressure is <90/60mmHg or decreased >20mmHg from baseline, MAP is decreased >10mm from baseline, CVP is <2mmHg and <6mmHg. Cont’s -Monitor the client for fluid volume deficit: poor skin turgor, dry mucus membranes sunken and soft eyeballs. -Measure intake and output accurately: report to the physician urine output <30ml /hour for 2 consecutive hours. -Weight the client daily on the same scales. -Administer IV fluid as described. Con’t… -Administer antiemetic medications to the client as prescribed. -unless contraindicated,maintain oral intake of at least 2500ml. HEALTH EDUCATIONS Advice the patients: -Avoid adding sugar to foods such as coffee and cereal. -Avoids food that are sweetened with sugar or honey,such as jellies,jams,cakes,and ice- cream. -Check blood glucose level regularly. -Limit intake of saturated fat and cholesterol in food. Cont’s… -Keep periodic appointment with health care providers for evaluation of bloods glucose control. -Be consistent about the amount,distribution and timing of nutrients. -Increase the amount of carbohydrate in a meal eaten before sustained exercise. SUMMARY Madam X admission on 17/3/2008.Was given IVF 3% Normal Saline 1pint 24 hours,Tablet Metaprolol 50g bd,Tablet Nifedipine 10g bd,Tablet Glicazide 160g bd,Tablet Pzayosin 1mg bd.Upon discharge on 19/3/2008 afebrile,vital sign stable,hypocount 5mmo/L.Patient has no hypoglycaemia or hyperglycaemia,attack or other complaint made.general condition satisfactory.
Solutions to Diabetes and Hypoglycemia (Translated): How to prevent and get rid of it in a natural way, without resorting to medicines but adopting a correct way of life